LAST NAME: ________________________				FIRST NAME: _____________________________				MIDDLE INITIAL: ___________________
NAME OF MEET: _____________________				DATE OF MEET: __________________________				HOME PHONE #: __________________
BIRTHDAY: __________________________				AGE: ___________		DAYS NOT ATTENDING: _________________________________
EVENT	#	FREESTYLE Time	#	BUTTERFLY Time	#	BACKSTROKE Time	#	BREASTSTROKE Time	#	INDV. MEDLEY Time
25		:          .		:          .		:          .		:          .
50		:          .		:          .		:          .		:          .
100		:          .		:          .		:          .		:          .		:          .
200		:          .		:          .		:          .		:          .		:          .
400 / 500		:          .								:          .
800 / 1000		:          .
1500 / 1650		:          .
(PLEASE PRINT)		# OF EVENTS ___________ X $ __________ = $ __________ + SURCHARGE OF ___________ = $ ___________ TOTAL (ENCLOSED)
Cut On Lines		#			Change Printer Setting To Print In Landscape					#
LAST NAME: ________________________				FIRST NAME: _____________________________				MIDDLE INITIAL: ___________________
NAME OF MEET: _____________________				DATE OF MEET: __________________________				HOME PHONE #: __________________
BIRTHDAY: __________________________				AGE: ___________		DAYS NOT ATTENDING: _________________________________
EVENT	#	FREESTYLE Time	#	BUTTERFLY Time	#	BACKSTROKE Time	#	BREASTSTROKE Time	#	INDV. MEDLEY Time
25		:          .		:          .		:          .		:          .
50		:          .		:          .		:          .		:          .
100		:          .		:          .		:          .		:          .		:          .
200		:          .		:          .		:          .		:          .		:          .
400 / 500		:          .								:          .
800 / 1000		:          .
1500 / 1650		:          .
(PLEASE PRINT)		# OF EVENTS ___________ X $ __________ = $ __________ + SURCHARGE OF ___________ = $ ___________ TOTAL (ENCLOSED)
Cut On Lines		#			Change Printer Setting To Print In Landscape					#